=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346577087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL MARIE JAXSON-JAGER III PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2009
-----------------------------------------------------
Last Update Date | 11/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 531 BELMONTE PARK N SUITE A
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45405-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-938-5642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 531 BELMONTE PARK N SUITE A PO BOX 1113
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45405-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-938-5642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C.0900539.TEMP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------